Archive for September, 2011

Sep 27 2011

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ryanb

Idle Hands are the Devil’s Playthings-

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I think that physical exercise can reap big benefits to the ATR recovery process, including:

  • Weight control - as we transition to a sedentary lifestyle, it’s easy to pack on the pounds.   In my case, I found myself famished the first few days after surgery, and made no effort to restrict calories as I knew my body was working very hard.    Over the long haul, I know that every pound I can take/keep off will reduce the load on my Achilles, and help reduce the risk of future/re-injury.
  • Improved circulation - I believe one of the reasons this injury is so slow to heal is because it has pretty poor blood supply.   Thermo therapy (heat) can help somewhat to increase localized bloodflow, but any activity to raise the heart rate (I think) should help, somewhat, to promote healing.
  • Preventing atrophy - use it or lose it they say.  Anything we can do to prevent atrophy is a good thing, especially for things like the quads and hamstring on the affected leg.   We’ve got enough issues to deal with on our rehab, without complicating it with preventable weakness to overcome.
  • Exercise of the ATR injury itself.   This is a tricky one, but the optimum rate of healing will come with just the right amount of stress on the tendon- something that will vary with time and the individual.    There is a big (Huge!) risk if you over-do it, but especially as we enter the PT phase, the optimal level of work for the tendon IS somewhere north of zero.
  • Mental health - everybody is different, but getting out and doing something… anything… has been a big help for me to stay positive.

You may have picked up on the fact that I’m not very compatible with a couch potato lifestyle.    The list of things I could not do with my rupture seemed impossibly long (running, hiking, ice skating, inline skating, mountain biking, road cycling, skiing… ).     Conversely, the list of physical activities I could do with this injury seemed depressingly short.

Weightlifting:

I (re)started lifting weights about a week after my surgery.   I initially made no attempt to do anything for my legs, and just focused on the upper body.   It was a bit of a puzzle to figure out modifications to the various exercises- so that I could do them kneeling on a bench, or seated.    I actually pulled my left (good leg) groin muscle a bit, trying to do 100lb dumbell rows from an awkward kneeling position.   As soon as I was full weight-bearing (walking) in the boot, I transitioned to doing the standing exercises, well… standing.    I also found that I could do leg extensions in the boot, without risk of hurting the ATR.   The tendency there is to pull your toes back- in a manner that would normally tug at the achilles; but my toes were fully restricted by the boot so I couldn’t pull on it.

Kayak

I recognized that paddling a Kayak was something I was going to be able to do early.   I had never done it before, but on day 20 I bought my first Kayak.   I take it out a few times a week, typically for an hour and a half or so- just paddling on reservoirs or lakes.   Getting my foot comfortable was a bit of a challenge -  I don’t wear the boot in the boat - and finally figured out how to rest it on a towel.   It’s not quite the cardio workout I had hoped for, just because my feeble arms run out of steam before I’m able to press my aerobic system.   But it’s fun; and I needed that.   In fact, I’m having enough fun with it, that it’s a sport I’ll probably stick with for the long haul, and we’re actually looking for a 2nd boat so my wife and I can go together.
Kayaking
That’s me, 1st day out in the Kayak (day 21)- boot on the dock. I really wish I could have worked this photo into the “Das Boot” post…

Walking

Not really a sport… but it’s been a very important part of my ATR recovery.   There seems to be a general consensus that walking is THE most important activity to get this injury rehab’d, and I’ve been getting out almost every day - on a dedicated walk - for at least a mile.   It’s also really been good to get out, talk the neighbors, and not feel like such a shut-in.

Spin Bike

A consistent story I found on the ATR blog was how much better everybody felt once they were able to start spinning an indoor spin bike.   My first attempt  (at day 21) did not go very well.   In fact, after probably just a minute, it was obvious that I was not ready.    Try 2, a week later, was more successful- I was able to spin (with essentially zero resistance) for 5 minutes.   By day 29 I was spinning for 20mins with very low resistance; basically just enough to keep the pedal motion smooth.   My experience was very consistent with what others had said;  the injury felt a whole lot better after the spin sessions.    I borrowed a spin bike for home use, and try to start each day with an easy 15mins, which really helps with that early morning soreness and stiffness.    I don’t have the objective (or the strength) to push it hard - typically my heart rate doesn’t get much above 100bpm.   So, even this isn’t giving me much of a cardio workout.
Spin!
That’s me on my borrowed spin bike- clipped into my road pedals which provide some added stability.

Swimming

I identified swimming as the activity I might be able to dive into - so to speak - earliest.   Stress on the Achilles should be low,  the water just doesn’t have the leverage to hurt the injury.   What I didn’t count on was the time for the incision to heal.   My doctors biggest concern might have been infection, and I promised him no swimming until it was fully healed up.   I also ceded the decision to my wife; and promised no swimming until she declared me healed up.   Finally on day 32 (today!) I got into the pool.   As I expected, swimming really didn’t stress or hurt the injury.  I was able to swim at nearly %100 (make no mistake, I am a terrible swimmer), and finally had an activity I could do to re-engage my cardio system.   Though I felt fine, I cut the session short at about 30 lengths- just to ensure that there are no unexpected effects tomorrow.  But I am very happy to be back doing something aerobic.   Curiously, my ankle actually felt better after the swim, not too unlike it does after a spin session.

Sorry, you don’t get a swim photo until I shed a few of these extra pounds.

Unfortunately, I think it’s now going to be quite a while until I can add any more new activities to my list.   The Utah weather will take Kayaking away from me here before too long. Next up is probably a slow transition to outdoor road cycling; but I see that being a long ways off. I’d be curious to hear what other sports/exercises people found themselves able to do through their recovery process and if they felt they were beneficial (or detrimental) to their progress-

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Sep 27 2011

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ryanb

Das Boot

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Day 19 post surgery brought the 2nd post op visit to my doctor. I had spent the previous 2 weeks with the modified version of the splint he (somewhat reluctantly) gave me. I had, for the most part, stayed completely off of the bad foot. I’ll admit to tapping the point of my toe down for balance when brushing my teeth.

I elevated it as much as I was able to.  Usually, I’d take the splint off, and as I was watching TV I’d trace out the alphabet with my toes in the air, or do other simple mobility exercises. By day 19 I had better than expected range of motion, and was able to articulate the joint against light resistance with the theraband. I started left-foot driving on day 9, and had returned to work on day 10 . Fortunately, I have a desk job, and was able to prop my foot up on a chair and keep it somewhat elevated there too.

I had even started going to the gym, hobbling around on crutches and finding variants of (upper body) lifts I could do kneeling, or sitting.

I anticipated another battle with my surgeon. My plan called for a boot at this point, and starting to do some static weight bearing. Given the battle over the cast/splint, I had a feeling the surgeon was not going to be very supportive of this idea.  To my surprise, after a short inspection - and without any prompting - the doctor declared it was time for a boot and to start gentle walking (with crutches for support).

I could not get into the boot "flat"- I had to use a wedge to prop up my heel ~30 degrees.      I also asked the doctor for some "Canadian Crutches" which I knew were going to be necessary for any extended walking in the boot.

My daughters school is conveniently 1 mile from my house. It’s a 2 mile round trip. I laid out a progression of steps… the idea being that as I was able to work up to 2 miles (without too much difficulty and/or pain) I’d move onto the next phase/configuration. The steps I imagined were:

  • Boot + heel lift, 2 crutches
  • Reduced heel lift, 2 crutches
  • No heel lift, 2 crutches
  • 1 Crutch + flat boot
  • Cane + flat boot
  • Walking in a flat boot
  • 2 Crutches, 2 Shoes
  • 1 Crutch
  • Cane
  • Walking in 2 shoes

That night (the day of my doctors appointment) I made it to the end of the block and back.   3 days later (day 22) I made it 2 miles.   On day 24 I took out the wedge, replacing it with a small footbed.     At day 26 I was back up to about 1.5 miles well on my way towards the flat boot.

But, then 2 things happened… first, my hands were taking a brutal beating.  They were calloused up, and I was having problems with my fingers going numb from pressure on the nerves.   Then, on day 27, I discovered I could do full weight bearing on the boot.   By the next day (day 28) I was walking pretty comfortably.  And by day 30, I was up over 1.5 miles- just walking (with the boot, and a very small heel lift).

Today is day 32.  Yesterday, I tried the fully flat boot- and discovered I’m not quite ready for it yet.   I went most of the day in that configuration, but when it came time for the long distance walk, I had to put the footbed back in.   I will probably wean myself off of it this week rather than go cold turkey.

The next step in my progression -and it’s a big one -  is 2 shoes.   I’m getting around the house a bit in that configuration;  sometimes (very carefully) without crutches.   But it’s hard to predict when I think I’ll be ready for dedicated walks that way.  I anticipate going back to 2 crutches when that happens, and my hands really are in no hurry to get back on them.

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Sep 27 2011

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ryanb

The Fork in the Road

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I learned that one of the guys who I race with suffered a complete rupture of his Achilles about a year before I did. Remarkably, he was back on the speedskates 4 months after his injury, racing at nationals a month after that, and had gone to the (Masters) world all around championships with me in February - approximately 7 months after his surgery.

This was in stark contrast to what everybody had told me about my injury: I was done for the year, no skiing, no skating, no more biking, get used to riding the sofa. This recovery story provided some much needed light at the end of the dark tunnel I was staring down.

So, during the immediate post-op recovery (the 5 days leading up to my 1st post-op doctors visit) I learned everything I could about his rehab schedule. Frankly, it sounded nuts at first… but it’s actually very similar to the rehab protocol posted at the achillesblog site here:

http://achillesblog.com/files/2008/03/achilles_tendon_repair_rehab.pdf

I think most doctors follow a prescribed protocol. For liability reasons, I’m not sure they can do much else- deviating from their procedure/protocol can only put them at risk. My doctors protocol was old-school, calling for long term immobilization. He wanted to put me in a hard cast for 6 weeks (not counting the 1st post-op week… 7 weeks total immobilization).

At my day 5 appointment, the big post-op wraps/cast were removed. The external suture came out. The wound was cleaned up, and covered with steri-strips. The doc examined it, and thought everything looked great.

In preparation for the meeting, I had faxed the doctor some information on the “new” protocol I wanted to follow… but I don’t think he’d had much time to look at it. He was ready to put me in the cast.

In the end, as the patient, I just had to assert myself and refuse the cast. I left with a hard “L” splint, which was secured with ace bandages. I could take it off to exercise the joint, and start the mobility exercises (light resistance with a thera-band). I could massage the calf muscle and within a few days was able to lightly flex it; it was surprising how hard it was to regain that motor control. I had the ability to keep a close eye on the wound for any signs of infection.

Sleeping posed the most challenge to comfort. The splint was hard, sharp, and it would shift around putting uncomfortable forces on my foot/ankle. After a couple of days, I cut the splint down so it didn’t hit the back of my knee, ground off the sharp edges, and padded it with a thin layer of foam. I finally learned the trick was to wrap it tighter - to keep it secure and stable - while sleeping, not “looser” for comfort. When I had it on (in bed) I invariably wanted it off. But, when I took it off, it didn’t take long before I wanted it back on. Slowly, my comfort level without it improved- and 15 days after surgery, I slept without it… and have slept with my foot free every night since.

One area where I did (for the most part) follow doctors orders was in care of the wound. One of the doctors biggest concerns was infection. I wore the splint in the shower, bagged, to keep the wound dry. Slipping in the shower was perhaps my biggest fear - and I was more than happy to have the support and protection of the splint in there. Day 15 was also the day when I took the first “wet” shower, without the splint/bag.

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Sep 26 2011

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ryanb

My Surgery

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I’m no stranger to injuries.   I broke my neck (compression fractured C5 and C6) playing hockey about 18 years ago.   I’ve been through a couple of bad motorcycle wrecks.   I used to race on the Velodrome and survived some bad crashes there.   I’ve been hit by cars, on my bicycle 5 or 6 times.   I badly injured by lower back lifting weights (sled press).  Tore a knee up wrestling.   Pretty much cut my left index finger off on a table saw…   The list goes on and on.

Yet, through all of that - as hard as it is to believe - I had not had surgery prior to my Achilles rupture (I’m not counting getting my tonsils out at age 4, or having doctors sew various lacerations back up).    In fact, I attribute my successful recovery from most injuries partially to always giving my body a chance to heal itself.

However, when I realized that my Achilles was completely torn, it seemed like a no-brainer: this was going to require a surgical repair.   During my 1st visit with my orthopedic doctor - just a few hours after the injury - we scheduled surgery as soon as possible - 2 days away.    To be honest, I would have done it that day if possible.

If you’re reading this blog- you’ve probably done the same research I did- and there’s a lot of info out there that suggests there may not be a huge benefit to surgery.   What I did learn though was that I was probably in the group of people who would most benefit from surgery - (relatively) young, very active, motivated for an aggressive rehab, and looking to return to athletics as soon as possible.   My doctor assured me that, even though I could still articulate my foot, that the tear was complete, showing me the “void” where the Achilles should be.

So, on Friday, 8/26/11, I had the surgery.    I gave the surgeon a camera, and told him I wanted pictures of:

  • What he found
  • How he fixed it

My surgery took about 1.5 hours.   One of the first things I asked to see was the picture of what he found.   And when I saw it, all doubts about getting this surgery were erased:
Hamburger
My heel is to the right, knee to the left. You can see that the heel end is broken pretty clean. The knee end recoiled into that tangled mess. It’s hard to see how that ever would have properly healed on it’s own.

The surgeon used what he described as high strength “Gore-tex like” sutures to assemble and pull it all back together. I think this picture is taken, while these sutures are taut, but before they are tied off. It’s interesting to note just how far the heel end of the tendon has been pulled. Prior to the surgery, this was all puddled down in my heel.
Sewed up.

I came out of the surgery completely immobilized, in a multi-piece hard-cast. The pain really wasn’t too bad- I used the industrial strength pain killers (Loretab) only on the day of surgery and that night. The next day (Saturday), I had progressed to over-the counter Tylenol. Sunday, I was off pain meds during the day- just using night-time Tylenol to get to sleep. I gave those up Tuesday night. I had my 1st post-surgery visit with the doctor on Wednesday, 5 days after surgery, and exactly 1 week after the injury.

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Sep 26 2011

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ryanb

Tendon Nutrition

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I used to do a lot of weightlifting; and one of the things I became absolutely convinced of was that nutrition plays a large role in recovery times.   We’d go really beat ourselves up at the gym, and the subsequent recovery time could vary from 3 to 6 days, depending - in part - on how the recovery was fueled.

There is an abundance of information (and product) available regarding nutrition to support healing/regeneration/recovery of muscle, yet I found a surprising lack of similar data (or consensus) on nutrition for tendon and connective tissue health.

I spent quite a while looking, and in the end decided to go with the shot-gun approach.   If somebody thought it would work, and could make a credible argument about why, I was going to try it.   I’m not terribly confident that any/all of this will really help much, but on the other hand - I don’t think it can hurt.    Starting about 2 days after my surgery, I started a regimen of:

All of that is taken twice daily.   Additionally, I’m supplementing my diet with:

  • Protein Powder (basic building block for most body tissue)
  • Jello (a full package daily of sugar free gelatin - loaded with connective tissue building blocks)

Supplements
Truth is, I’ll probably never really know if any of this stuff is helping.    If I was a betting man - after all my research -  I’d probably put my money on the Jello and proteolytic enzymes as having the best chance of making a positive difference.

** I provided the links for info, so you could know exactly what I was using. They are not meant to be endorsements or suggestions for any particular product.

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Sep 24 2011

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ryanb

My Injury

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So, it looks like I’ve got a blog…

First, about me:  My name is Ryan.   I’m 46.   I live in Utah.   Married, 2 kids.   I’m a very active guy- my activities include cycling, alpine skiing, hiking, back-country skiing, and speedskating.   I’m 5′9, around 190lbs.
Skating
I completely ruptured my right Achilles tendon on Wednesday, 8/24/2011.   I was in the parking lot at work, during my lunch-break, working on my speedskating starts.    In retrospect, I believe it was a combination of several factors that contributed to the injury:

  • Hard explosive effort from a stand-still
  • Running up a moderate hill
  • A 40lb weight-vest
  • Vibram 5-finger shoes (no cushion & no heel-lift)
  • Running on a hard surface (Asphalt)

I had done stretching, and plenty of warm-up.   The injury happened on about start #12.   It was ~95 degrees outside, if anything I was perhaps a little dehydrated and hot.

Because I was practicing starts for speedskating, I had started out duck-walking (running) with my toes pointed out.   I had built up speed and was transitioning into a full (toes forward) run when it snapped.   I was 10-15 steps into the effort.

Like others have described, the sensation was that I had been hit hard in the calf.   It felt like somebody had thrown a brick at me.   I thought that perhaps a weight had fallen out of my vest and hit me- though the impact seemed more severe than that would explain.   I did not fall down.   In fact, I stopped and turned around to try and figure out what had just hit me.

One of the things that puzzles me is that there was absolutely zero warning. No soreness, no weakness, no instability, no hints whatsoever from my Achilles that I was at the precipice of a catastrophic injury. With 20/20 hindsight, I’m not sure what I could have done to see this coming and back off accordingly.

Walking back to the bottom of the hill, it became apparent that I was badly hurt.   My car was parked at the bottom of the hill, and by the time I had my gear off, I had decided I needed to seek medical care.  I drove myself to a nearby urgent care clinic (with my still somewhat functional right foot).   On the way, I sort of went into shock- an adrenalin crash perhaps.   I pretty much lost the feeling in my arms,  and nearly blacked out.    It was as if I had really badly hyper-ventillated; yet my breathing was calm and under control.     The doctors at the urgent care clinic seemed concerned that I might be having a cardiac issue, though I could tell the issue was chemical/systematic.

The urgent care doctor did not diagnose a ruptured Achilles.   He thought I had torn my calf muscle.   They arranged for an appointment with an orthopedic doctor the following week.    Not wanting to wait that long, I contacted an orthopedic surgeon who had done work for our family- he agreed to see me within a couple of hours.

My doctor did an examination, and concluded that this was an obvious rupture of the Achilles.   We scheduled surgery for Friday 8/26- two days after the injury.

I spent the next couple of days reading everything I could.   Because I still had some function and mobility with my foot, I started to wonder if my tear was truly complete.   Also, there seemed to be a lot of information casting doubt on the benefits of surgery vs. the risk.   But, because I am so active, and had designs on getting rehabilitated as soon as possible, I did decide to go ahead with the surgery as scheduled.

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